In-Hospital Cardiopulmonary Resuscitation in Patients Receiving Maintenance Dialysis: Glass Half Full or Half Empty?

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Nearly 300,000 Americans experience in-hospital cardiac arrest each year. Patients receiving maintenance dialysis treatment account for a substantial proportion of these cardiac arrests; it has been previously reported that 17% of all in-hospital cardiac arrests occur among patients receiving maintenance dialysis. Historically, the outcome of in-hospital cardiopulmonary resuscitation (CPR) among individuals receiving maintenance dialysis has been deemed to be poor. Previous studies have shown a lower survival after in-hospital cardiac arrest among patients receiving maintenance dialysis than other populations; however, these findings could have been in part related to confounding and underreporting of CPR events as well as the resuscitation strategy and perceptions of futility. Advances in CPR have resulted in significant improvements to hospital survival after an in-hospital cardiac arrest. Accordingly, more specific information about in-hospital CPR outcomes for individuals receiving maintenance dialysis would help guide life-sustaining treatment decisions for this vulnerable population that, on average, experiences 2 hospitalizations each year.

In this issue of Kidney Medicine, Saeed et al conducted a retrospective cohort study of 184 patients receiving maintenance dialysis who experienced an in-hospital cardiac arrest and underwent CPR within Cleveland Clinic Foundation hospitals between 2006 and 2014. They used billing diagnosis codes to identify individuals receiving maintenance dialysis who were receiving in-hospital CPR and subsequently collected detailed information on patient comorbid conditions, CPR duration, initial cardiac arrest rhythm, in-hospital outcomes, and discharge disposition, with the goal of identifying how these factors were associated with CPR outcomes. Among these 184 patients, 133 (72%) of patients survived initial CPR; however, only 50 (30%) patients survived to hospital discharge. Of these 50 patients, only 18 (10%) patients were able to be discharged to home. The only significant predictor of unsuccessful CPR was longer duration of CPR; longer CPR duration as well as older patient age predicted overall in-hospital mortality, with a 15% increase in the odds of death with each minute increase in CPR duration and a 64% increase in the odds of death with each 10-year increase in age. Only patient age was associated with discharge to home after cardiac arrest. Among patients who survived initial CPR, survival to hospital discharge was approximately 25% if CPR duration exceeded 20 minutes and 25% for patients who were aged 80 years or older. Surprisingly, patient comorbid conditions, the presenting cardiac arrest rhythm, and dialysis vintage did not predict any of the survival outcomes examined.

Although these findings should be interpreted with some caution, given the small sample size drawn from a single institution, placing these findings in the context of previous studies helps us understand the clinical value. First, it is important to note that the CPR survival outcomes were remarkably similar to, if not better than, those reported by prior analyses. The survival to discharge rate of 30% is generally consistent with observations from several larger nationwide cohorts of individuals receiving maintenance dialysis with in-hospital cardiac arrest during a similar time frame (23%-25%), increasing confidence in citing this expected outcome range in discussions with patients., Second, although this study did not compare survival outcomes with patients not receiving dialysis from their institution, 30% survival to hospital discharge is also comparable to or perhaps even better than outcomes seen in patients not receiving dialysis. In 2014, survival to hospital discharge was 25% for all patients in the American Heart Association’s Get With The Guidelines registry of in-hospital cardiac arrests. A recent analysis using this registry that directly compared age-matched and comorbid condition–adjusted cohorts of patients receiving dialysis and those not receiving dialysis found no difference in hospital survival following CPR. Additionally, as discussed by the authors, the relationship between the duration of CPR and chances of survival to hospital discharge in individuals receiving maintenance dialysis are also quite similar to those observed in other in-hospital cardiac arrest populations.

Viewed in a positive, or glass half full, light, patients receiving maintenance dialysis appear to fare no worse or perhaps even better than other patients, dispelling any justification for “renalism” (decreased efforts to provide therapeutic interventions due to concerns for futility or harm specifically among patients with kidney disease) when it comes to in-hospital CPR. However, viewed negatively, or as a glass half empty, the overall 30% hospital survival rate certainly does not justify painting a rosy picture of the efficacy of CPR. Importantly, given prior reports of what matters to patients and their families, the 10% discharge to home is sobering. Additionally, this study did not report long-term survival outcomes after discharge, which has been reported in prior studies to be as short as 5 months for individuals receiving maintenance dialysis with in-hospital cardiac arrest.

Taken together, this study adds to the growing body of evidence that should assist us in having more transparent and informed life-sustaining treatment discussions with patients about what outcomes to expect in the event of in-hospital cardiac arrest. The added information on CPR duration, patient age, and outcomes also provides some new prognostic information that could be helpful in guiding level-of-care discussions for patients receiving maintenance dialysis who remain seriously ill after surviving the initial arrest. Equipped with these data, the onus is now on providers who care for individuals receiving maintenance dialysis to have important, realistic discussions that neither upsell nor downplay the potential efficacy of in-hospital CPR.